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OPINION
Valuing people1 and Valuing peoples oral health2 both advocate choice and inclusion for people with learning disabilities.
Research suggests that services and policy and guidance, while prescriptive and available, have not been effective in reducing oral health inequalities for people with learning disabilities. There is a risk that specialist services led by newly created
consultants in special care dentistry may have the unintended effect of reducing choice if general dental practitioners are
encouraged to refer all those with learning disabilities. A modified model of access is proposed that primary care organisations could use as a commissioning tool for dental contracts to facilitate choice and maximise involvement in oral health
care for those with learning disabilities.
Background
In the UK, over 985,000 adults are registered as having a learning disability;
796,000 are aged 20 or over yet only 20%
of them are known to the learning disability services. By 2021 it is predicted
that there will be more than one million
people with learning disabilities in the UK.3
In light of the recent debates around specialist services for people with disabilities
in the dental literature,4-8 this predicted
increase has implications for the delivery
of services in the UK.
Valuing people 1 was written with the key
principles of Rights, Choice, Independence
and Inclusion at its heart. Its origins came
from the historical omission of people with
learning disabilities from health policy. Its
aim was to ensure that people with learning disabilities are not excluded from their
choice of services so that their rights and
dignity of independence are maintained
and wherever possible they are able to
access the same services as people without disabilities. Valuing peoples oral
1*-3
Refereed Paper
Accepted 1 February 2010
DOI: 10.1038/sj.bdj.2010.204
British Dental Journal 2010; 208: 203205
Definitions of disability
and the Steele report
The definition of disability as identified by
the Joint Advisory Committee for Special
203
2010 Macmillan Publishers Limited. All rights reserved.
OPINION
a reduction of choice of services for people with learning disabilities in particular
if practitioners are encouraged to refer to
specialist services all patients perceived to
fall within it. This is of particular concern
for such groups when need for care is often
not expressed as demand and when they
are often unable to choose.
The definition of a learning disability
in Valuing people is: the presence of a
significantly reduced ability to understand new or complex information, to
learn new skills (impaired intelligence),
with a reduced ability to cope independently (impaired social functioning); which
started before adulthood, with a lasting
effect on development.1
The International Classification of
Mental and Behavioural Disorders10 categorises people with learning difficulties
in terms of their measured level of intelligence or Intelligence Quotient (IQ). For
example, categorisation of a learning difficulty (disability), according to the world
of medicine, means an IQ of 50-69 (mild),
35-49 (moderate), 20-34 (severe) and less
than 20 (profound), alongside detailed
clinical descriptions of each category.
Any IQ measurement above 70 is within
normal limits. Even though Valuing people and various other authors11,12 dislike
these definitions because diagnosing a
person with learning disabilities separates
them from the normal population, and IQ
alone is not a sufficient reason for deciding
whether individuals should be provided
with additional health and social care
support, for the purposes of this paper it
is probably useful to use these categorisations to illustrate which categories cause
the authors concern. People with moderate/severe to profound impairments should
have a specialist dental service because
they are most likely to need one-to-one
care and support, and are more likely to
have higher needs. Whereas not all people
with mild to borderline moderate learning
disabilities will necessarily need specialist
dental care. There appears to be an argument for the provision of case by case
consideration and not lumping people
together under one category.
One way of ensuring that a dental contract is developed with clearer incentives
with the inclusion of discretionary payments for non-salaried dentists to allow
for the extra time required when working
204
OPINION
learning disabilities rests with PCOs. Using
the described modified model of access as a
commissioning tool for new contracts may
ensure all areas of access are optimised,
facilitating choice and inclusion, respecting individual rights and independence,
and enabling an increase in quality care.
7.
8.
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10.
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Fiske J. Special care dentistry. Br Dent J 2006; 200: 61.
Department of Health. NHS dental services in
England: an independent review led by Professor
Jimmy Steele. London: Department of Health, 2009.
Department of Health. Choosing better oral health.
An oral health plan for England. Gateway ref: 4790.
London: Department of Health Publications, 2005.
World Health Organisation. The ICD-10
Classification of Mental and Behavioural Disorders.
Geneva WHO, 1992.
MacKenzie F. The roots of biomedical diagnosis.
In Grant G, Goward P, Richardson M, Ramcharan
P (eds). Learning disability: a life cycle approach to
valuing people. England, New York: Open University
Press, 2005.
Dumbleton P. Words and numbers. Br J Learn Disabil
1998; 26: 151-153.
Hallberg U, Klingberg G. Giving low priority to oral
health care. Voices from people with disabilities in
a grounded theory study. Acta Odontol Scand 2004;
65: 265-270.
Davies K W, Holloway P J, Worthington H V. Dental
treatment for mentally handicapped adults in
general practice: parents and dentists views.
Community Dent Health 1988; 5: 381387.
Nunn J H, Murray J J. Dental care of handicapped
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2010 Macmillan Publishers Limited. All rights reserved.